Abdomen

DEFINITION

(1) Acute abdomen === the term an acute abdomen denotes any sudden
spontaneous non traumatic disorder whose chief manifestation is an acute
attack of abdominal pain and for which urgent operation maybe necessary .
acute abdomen designates symptoms and signs of intra-abdomen disease
usually treated best by surgical operation .

(2) Guarding=== the detection of increased abdomen muscle tone during

palpation is called guarding .Guarding maybe voluntary ,involuntary ,localized
or generalized . To detect guarding ,the the examiner should press gently but
slowly and firmly on the patient’s abdomen .

(3) BOARD LIKE abdomen ===it is the characteristic of perforated duodenal ulcer .
if after asking the patient to relax and breathe deeply , the muscle remain rigid
or tense, it indicates involuntary guarding , which means underlying peritonitis
. generalized intense guarding produces the board like abdomen .

(4) Rebound tenderness==== is a sign of peritonitis. To detect rebound

tenderness, the examiner presses deep into the patient’s abdomen with
flattened fingers . sudden withdrawal of that hand may cause an increase in
the abdomen pain ,and this symptom indication peritonitis

Q1) what are the type of acute abdomen pain ?

ANS --. Visceral pain : this is the pain you feel when your internal organs , or
are damaged in your body . you may feel a dull , cramping , or burning pain
that builds up slowly . You may feel pain down the middle of your stomach , or
you may not be able to feel exactly where it is

Parietal pain : this type of pain usually felt after a sudden injury. An injury
can cause urine ,pus bile ,or other contents to leak and hurt the lining of your
abdomen . parietal pain starts suddenly , feels sharps , and you can feel where
it is in your abdomen
 Referred pain : this pain felt in a part of the body that is far from the actual
cause of the pain . referred pain may be felt when a nerve is hurt or pressed on .

Q 2) What CAUSES ACUTE abdominal pain ?

ANS-- in some cases , the cause is acute abdomen pain is unknown . in other
cases , the pain maybe caused by one or more of the following;

 Abscess ( collection of pus ) in the liver or other organs.

 Bowel blockage , peptic ulcer , or rupture( tearing a part ) of the esophagus

or spleen .

 Diseases of the blood or blood vessels .

 Inflammation (swelling ) in the esophagus , stomach , intestine ,or other

organs in the abdomen

 Injuries, treatment , surgery or heat or radiation therapy .

 Swelling or stone in the kidney or gallbladder .

 If you are female , having your unborn baby outside of the uterus
(womb) ,disease of the fallopian tube or ovaries , or menstrual ( monthly
period ) pain .

Q3) how to diagnose an acute abdomen ?

ANS-- Characterization of pain and location of the pain and duration

Other symptoms- vomiting bloody.

Examination of acute abdomen inspection , auscultation , percussion ,palpation

, laboratory studies and imaging test

Definition
1. Rectal ulcer—Solitary rectal ulcer is a condition in which typically a single ulcer
occur in the rectum. Producing sign such as Rectal bleeding with straining when
you pass bowel movement.

àIn some cases, however rectal ulcer syndrome can result more than one
lesion or in the lesion that are not ulcers.

àThis rare and poorly understood disorder occurs in the people with chronic
constipation and may be due to injury to the rectum. Solitary rectal ulcer can be
recurrent. Treatment for this range from changing your diet and fluid intake in
mild cases.

2.Anal Fissure—It is a spit in the endoderm, usually in the midline, just distal to
the dentate line.

àFissure result from forceful dilation of the anal canal, most commonly during
defecation. The endoderm is disrupted exposing the underlying internal sphincter
muscle.

àGoligheter’s rule is that 90% of anal fissure are posterior , 10% anterior and
<1% are on both side ant. And post.

FILL IN THE BLANKS

Q1-Masive gastric anatomy tract bleeding main causes—

1. Esophageal varices

2. Duodenal peptic ulcer

3. Gastric ulcer

4. Gastritis

5. Mallory Weiss syndrome

Q2. Dumping syndrome—2 categories

Ans: 1. Cardiovascular
 2. Gastrointestinal

Q3. Pathologic categories of thyroid?

Ans—4 type of thyroid disease

1. Hyperthyroidism

2. Evolution of thyroid nodules and Goiters

A) Thyroid nodules

B) Simple or Non toxic goiter

3. Inflammatory thyroid disease

a) Acute thyroiditis

b) Sub acute thyroiditis

c) Hashimoto’s thyroiditis

4. Malignant tumor of the Thyroid

a) Papillary adenocarcinoma

b) Follicular aden carcinoma

c) Medullary carcinoma

d) Undifferentiated carcinoma

Q4. Hemorrhoids?

Ans—They occur due to increased Intra-abdominal pressure. This is due to

1) Obesity

2) Pregnancy

3) lifting
 APPENDIX

Acute appendicitis diagnosis:

 Abdominal pain

 Anorexia, nausea, vomiting

 Coraloed right lower quadrant abdominal

tenderness

 Low grade fever

 Leukocytosis

Symptoms and signs:

 Vague mid abdominal discomfort

 Nausea, anorexia and indigestion

 Persistent pain

 The patient may feel constipated

Reraly, the cecum may lie on the left side of the abdomen and
appendicitis may be mistaken for sigmoid diverticulitis.

An inflamed appendix in the right upper quadrants may mimic acute

cholecystitis or perforated ulcer.
 IMAGING STUDIES

 Localized air – fluid levels, localized illus or increased soft tissue

density in the right lower quadrant is present.

 Coliculos in the right lower quadrant coupled with pain

 Perforated peptic ulcer

 Barium enema

 Ct for enlarged appendix

Diagnosis

 Localized pain

 Tenderness

 Inflammation (fever, leucocytosis)

 Migration of pain from periumbilical area to the right lower

quadrant.

DIFFERENTIAL DIAGNOSIS

 Children:

 Acute gastroenteritis

 Mesenteric lymphadenitis
  Meckel”s diverticulitis

 Intussusception

 Adults:

 Terminal ileitis

 Ureteric colic

 Right sided acute pyelonephritis

 Perforated peptic ulcer

 Acute pancreatitis

 Adult female:

 Pelvic inflammatory disease

 Mittelschmerz

 Torsin or heamorrhage of an ovarian cyst

 Ectopic pregnancy

 Elderly:

 Sigmoid diverticulitis

 Carcinoma of the caecum

COMPLICATIONS

 Perforation

 Peritonitis
  Abscess

 pylephlebitis

TREATMENT: CEPHALOSPERIN A DRUG

APPENDECTOMY

A. Incision

B. After delivery to the tip of cecum the mesoappendix is

divided

C. The base is clamped and lighted with a simple throw of the

knot

D. A clamp is placed to hold the knot during inversion with a

pursed tring to tore of fine silk

E. The loosely tide inner knot on the stump assures that there is
no closed space for the development of a stump abscess.

Heart

Types of valves- two types 1) biological/bio-valve

2) Mechanical valve
 1. Biovalve- 3 types which are used for replacement of diseased heart vessels.

a) Stented porcine bioprosthesis-

-it is used because of its lwo incident of thrombo-embolic events

-post operative anticoagulation is not necessary for this valve

- stented porcine valves are prone to structural failure from leaflet

calcification (or) leaflet stent defiscence.

b) stented pericardial valves

- This reduces the severity of structural failure

- 80% of patients are free from structural failure.

c) stentless porcine valves

- It is used for aortic valve replacement

- This valve has low transvalvular gradient and faster regression of ventricular
hypertrophy.

-Pulmonary auto graft replacement of aortic valve (Ross procedure)

It is an another biologic option

Outcomes are similar to those achieved with aortic allografts.

2) Mechanical valves

Most commonly used, which include tilting disk and bileaflet types.

Due to adequate anticoagulation, thromboembolish can occur for which Warfarin

therapy is required in sufficient closed.

St. Jude valve offers lowest transvalvular gradient and largest affective orifice.
3. Coronary artery disease (CAD)—A condition that reduces the blood flow
through coronary arteries to heart muscles due to fat deposition inside the
arterial wall.

In this atherosclerosis of coronary arteries occurs, which may cause angina
pectoris, MI, and sudden death.

Risk factors includes Hypertension, D. mellitus, Low level of HDL.

4. Coronary artery bypass graft( CABG)-- Conventional method for surgical

treating ischemia heart disease.

A type of surgery used to bypass a blockage, is one of the blood vessel that
supply the heart muscles.

The surgery involving cutting the affected coronary artery above and below the
blockage, then attaching a small loop of vein(saphenous) or Artery(mamillary) to
each. Creating a new circuit ; on bypass through which blood mau flow.

This may improve blood supply to muscles of heart and relives angina pain

Liver diseases

1) Associated ligaments

a) Left and right triangular ligament

b) Coronary ligament

c) Falciform ligament

d) Ligament teres hepatis

e) gastro hepatic ligament

 f) Duodenole ligament

2) Hepatic cedicle

a) Portal vein

b) Hepatic artery

c) Hepatic vein

d) Bile duct

e) Lymph duct

f) Lymph node and nerve

3) Primary hepatic carcinoma- etiology and etiopathogenesis is not definite

now.

a) Hepatic cirrohis

b) Vitrous hepatitis

c) Some chemical carcinogen like flaracin

d) Environmental factors.

4) Pathogenecity-

a) Initiation

b) Promotion

c) Transformation

d) Progression

5) Types of primary hepatic carcinoma

a) Nodus

b) Huge lump
 c) Suffusion

6) Classification of tissue pathology

a.i) Hepatic cell type

a.ii) Bile duct cell type

a.iii) Mixed type

7) Route of metastasis

a.i) Dissemination of liver

a.ii) Hematogenous metastasis ( lung> bone > brain)

a.iii) Lymphatic metastasis

a.iv) Direct spread

a.v) Abdominal cavity plant

8) Natural course –

a.i) Earlier subclinical stage

a.ii) Subclinical stage

a.iii) Intermediate stage (60%)

a.iv) Advanced stage (20%)

9) Clinical manifestation- -> lack of typical symptoms in the earlier stage

a.i) Frequent clinical manifestation

a) Pain in hepatic region, loss of appetite

b) Debility , athrepsy, abdominal distension

c) General and digestive symptoms

d) Metastasis symptom, hypoglycemia, globulism

10) Complications-

a) Heptic coma

b) Upper GI hemorrhage

c) Rupture and hemorrhage of carcinoma

d) Secondary infection

11) Diagnosis

a) History

b) Physical examination

c) Laboratory

c.i) Hematology exam

c.ii) CT, CTA

c.iii) USG

c.iv) MRI

c.v) Liver biopsy

12) Lab finding

a) AFP>900 µg/l

b) Liver function, LDH, AKP, FGT

c) Hematology exam

d) Other tumor marker, Y GT II , etc

13) Surgery types

a.i) Local resection- sub-segmental or segmental hepatectomy, lobe or half

liver, even right rhree loves resection, irregularly partial hepatectomy.
 Caution:

Remain> 30% of the normal liver tissue

Remain > 50% the cirrhotic liver tissue.

14) Treatment of recurrence:

a.i) Regular follow up

a.ii) Monitoring AFP + B-USG

a.iii) Excise the new growing tumor again

15) Hepatic cyst:

a.i) often with polycystic kidney

a.ii) epigastric distention , pain, abdominal mass

a.iii) AFP normal, Liver function Normal

a.iv) USG, CT has diagnostic valve

a.v) Treatment capsule wall partial excision

16) Bacterial liver abscess: clinical manifestation

a.i) Shake , high fever, hepatic region pain

a.ii) Temp 39-40 c remittent fever

a.iii) Toxic symptom such as profuse swelling , nausea, vomiting, loss of

appetite and debilitation

17) Laboratory examination

a.i) Blood routine WBC (High) , anemia

a.ii) X-Ray , raised diaphragmatic muscle and limitation of movement , liver

shadow increased or has local eminence
 a.iii) B-USG can discern abscess

18) Treatment-

a.i) Correct fluid and electrolyte balance

a.ii) Enough nutritional support

a.iii) B-USG, CT guided puncture drain

a.iv) Lobectomy of liver is reasonable if there is chronic local thick wall

abscess.

THYROID

Nerve Supply: Superior laryngeal nerve, i) Separated from the vagus nerve.
ii) The smaller external branch (cricothyroid muscle).
Blood Supply : 4 main arteries – pair of The Superior Thyroid
Pair of The Inferior thyroid.
And 3 veins.
Benign Thyroid Disease :
i) Endemic Goiter - Diffuse goiter. Nodular goiter
ii) Thyroiditis – Acute supparative.
Subacute Thyroiditis.
Chronic Thyroiditis – Hashimoto’s thyroiditis. Riedel’s Thyroiditis (struma).
Causes of Hashimoto’s thyroiditis :
i) A cause of hypothyroidism in adult.
ii) Immune complex and complement.
iii) An exacerbation of immune response.
iv) An infiltration of lymphocytes.
v) TSH – blocking antibodies.
vi) A hypothyroid clinical state.
Causes of Hyperthyroidism in short :
i) Grave’s disease.
ii) Toxic nodular Goiter.
iii) Toxic thyroid edema.

Clinical presentation of Hyperthyroidism :

i) Physical examination.
ii) Increased hypermatabolicstate.
iii) Cardiovascular stress.
iv) GI sign.
v) Psychiatric signs.
vi) Genital disorder.
vii) Extra thyroid presentation – vitiligo, pretibial myxoedema, sweating, weight
loss, heart intolerance and thirst.
Treatment :
A] Radioiodine ablation.
B] Antithyroid medication – The main action of drugs PTU Methiamazole and
Carbimazole is via the inhibition of the organification of the intrathyroid iodine as
well as inhibition of the coupling of the idotyrosine molecules to form T3 and T4.
Patients with severe thyrotoxicosis initially starts with β blockers as propanolol.
C] Surgery.
Toxic Nodular Goiter – toxic Adenoma (Plummer’s disease)
i) Autonomous function.
ii) Independent of Tsh control.
iii) Symptoms – mild, peripheral.
iv) Thyroid harmone increase, TSh decrease, Antithyroid antibody decrease.
Preoperative Preparation :
i) BMR examination and general examination.
ii) Antithyroid medication.
iii) The lygol. iv) The β Blocker.
Operation Complications :
i) Bleeding.
ii) Recurrent Laryngeal nerve injury.
iii) Superior Laryngeal nerve injury.
iv) Hypoparathyroidism.
v) Thyrotoxic storm.
vi) Hypothyroidism.
Pappillary Carcinoma :
Clinical Presentation: i) Dysphagia.
ii) Mitary painless masses.
iii) Cervical tenderness.
iv) Painful neck mass
v) Superior venacava syndrome.
Treatment : Surgical ablasion.
Follicular Carcinoma :
Treatment :
1) Thyroid lobectomy and ishmectomy
< 2 cm well contained with one thyroid lobe.
2) Total thyroidectomy
> 2 cm [4 cm]
3) Lymph node dissection.
4) Radio iodine treatment.

Surgical Approach :
A mutiorner retracted is inserted and bowels are placed so that only the incision
is exposed. The strap muscles (Sternohyoid, sternothyroid). Then separated by –
tissues in the avascular midline plane from the thyroid cartilage to the
suprasternal notch. The thyroid exposed by mobilizing the strap muscles away
from the lobe means of alateral retraction on the muscles and blunt dissection of
a kweatiner peanut peanut dissector. The midline vein is exposed and ligated.
Total Lobectomy -:
The branch of interior thyroid artery are – at the surface of the thyroid gland. The
interior thyroid veins can now be ligated and superiorly, the CT (ligament of
berry), which binds the thyroid to tracheal rings, is carefully. They are usually
several to the thyroid and most vulnerable at this point. Division of ligament at
this point allows the thyroid to be mobias medially.
Subtotal Lobectomy :
Necessitates the identification of the parathyroid glands, inferior artery and
recurrent laryngeal nerve. The line of resection is selecs to preserve the
parathyroid glands and their blood supply are to protect the recurrent laryngeal
nerve. It should bebased on the inferior thyroid artery or its major branches.
Risk :
i) Ligament of berry.
ii) During the ligation of branches of the inferior thyroid artery.
iii) at the thoracic inlet.
Q) .How many lobes did the thyroid divided into – 2 lobes
Q) .How many harmones does thyroid secrete – Thyroxine T4 , Tridothyronine T3

Others
Q. 1 Principle indication for the removal of nodular goiter ?

Ans.. The principle indication for surgical removal of the nodular goitar are

1) Suspicion of cancer

2) Symptom of pressure

3) Hyperthyroidism

4) Sub sternal extension

5) Cosmetic deformity

Solitary hard thyroid nodules that are cold on the radioiodine scan and

Solid on the ultrasound or suspicious of caner on the aspiration biopsy

Cytology should be removed

Q. 2 Please list the treatment option for non bleeding varices caused by portal
hypertension on the paper ?

Ans…. The treatment option of expectant management endoscopic

sclerotherapy ,propanolol,
 Portasystemic shunts, devascularisation of the esophagogastric juntion &
miscellaneous rarely used

Operations the treatment of the patient with varices that have nerve bled is
usually referred to as a prophylactic propanolol .

Q3 Treatment option for the primary liver cancer ?

ANS--The treatment option for the primary liver cancer are

1) Surgery type 2) hepatic artery ligation 3) hepatic artery embolism

4)liquid nitrogen frozen 5) hepatic artery chemoembolization 6) laser
gasification 7) microwave heat cure

8)portal hepatectomy 9) treatment of the recurrence . 10) liver

transplantation 11) gene therapy

Q4 Please list the differential diagnosis of the hemorrhoid bleeding ?

ANS…. Blood in the pleural space usually occurs secondary trauma surgery ,
diagnostic or therapeutic Procedures neoplasm’s pulmonary infraction
and infection (TB).

Q5-- Differential diagnosis of hemorrhoids ?

ANS…. Painless bleeding attributed to hemorrhoid must be distinguished from

the rectal bleeding from the colorectal malignancy, infilammatory bowel disease
diverticular disease and adenomatous polyps painful bleeding associated with the
bowel movement is caused by a rectal ulcer or the anal fissur , straining at the
stool is more often caused by obstructed defecation than hemorrhoids

Q5-- The principles of lung cancer treatment

ANS… the treatment of the small cell carcinoma consist primarily of chemothera

And radiation, but for early disease resection may improve the local control and
result in increased long term survival
Stage 1-a/b: surgical resection

Stage 2-a/b:surgical resection +/-XRT or chemo

Stage 3- a: initial chemo,surgery , +/- XRT ( no surgery if contralateral or bilateral

mediastinal nodes )

Stage 3- b : range from the palliation to chemo and XRT

Stage4: chemo or palliation

Multiple choice questions

 What is the most imp reason for prehapatic portal hypertension?

 Congenital Artesia or stenos is

 Thrombosis of portal vein

 Thrombosis of splenic vein

 Extensic compression(ex: tumors)

 What is portal venous pressure?

P=F×R

Ranges from 7-10mmhg

 What is the most frequent cellular type of primary liver cancer?

 Hematoma(hepatocelluler cancer) -80 present

 Most imp test for primary liver carcinoma?

 AFP

 Most reliable symptoms for acute appendicitis

 Migrating pain
 Most reliable test for breast cancer

 Open excisional biopsy

 Types of thyroid includes:

 Papillary adinocarcinoma

 Folicular adinocarcinoma

 medullary carcinoma

 undifferentiated carcinoma

 pathological type of primary liver cancer:

 hepatocelluler carcinoma

 cholengeocelluler carcinoma

 mixed form(hepatocholangeoma)

 patholagical type of lung cancer:

 squamous cell carcinoma

 adenocarcinoma

 small cell carcinoma

 largcell carcinoma

 adinosquamus tumor

 branchial gland adinoma

 hemorrhoid can be classified into:

 internal

 external

 symptoms of dumpling syndrome fall into:

 cardiovascular

 gastrointestinal

 all hernias of the abdominal wall consist of a peritoneal sac that protrudes through muscular
layers of abdomen